Taking Care of Disadvantaged Patients
Am Fam Physician. 2017 Jan 15;95(2):118-119.
I find myself feeling frustrated and burnt-out when caring for patients with limited means. I am not adequately prepared to handle their nonmedical needs. For example, I have a 62-year-old patient with hypertension who lives with her relatives near my practice. She recently emigrated from Ghana and speaks very little English. She has no medical insurance. Her family is low income and speaks English fairly well. Her son usually accompanies her to appointments and serves as her translator, which I know is inappropriate.
For the past couple of months, I have attempted to address my patient's hypertension with escalating dosages of several medications. Despite treatment, her blood pressure is still around 190/110 mm Hg. I suspect that she is not taking her medication properly, although (through her son) she says she is. Because of reassuring basic laboratory test results, I do not suspect a secondary cause of hypertension. Evaluation for uncommon causes of hypertension is beyond what she can afford.
My quality metrics suffer because the preventive measures and chronic disease status markers of my patients such as this one are not good. I am not about to dismiss them from my practice, but what can I do?
No single person can be responsible for the health of a population. However, there are a number of strategies for taking care of members of disadvantaged populations.1 These range from targeted compassion and interventions for the individual patient to broad advocacy for disadvantaged groups. Increasingly, as the nation's health care system prepares for an era of pay-for-outcomes, hospitals and insurance companies are developing resources to address the challenges disadvantaged patients often face, and they are sharing these resources with community physicians. In addition, for perhaps the first time, private and public sector entities are collaborating and coordinating resources to become more effective partners in the care of vulnerable patients. Finally,
1. Czapp P, Kovach K; American Academy of Family Physicians. Poverty and health—the family medicine perspective (position paper). 2015. http://www.aafp.org/about/policies/all/policy-povertyhealth.html. Accessed January 10, 2015.
2. National Quality Forum. Risk adjustment for socioeconomic status or other sociodemographic factors. http://www.qualityforum.org/Publications/2014/08/Risk_Adjustment_for_Socioeconomic_Status_or_Other_Sociodemographic_Factors.aspx. Accessed January 10, 2015.
3. U.S. Department of Health and Human Services, Office of Minority Health. National standards for culturally and linguistically appropriate services in health and health care: a blueprint for advancing and sustaining CLAS policy and practice. April 2013. https://www.thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedCLASStandardsBlueprint.pdf. Accessed January 10, 2015.
This series is coordinated by Caroline Wellbery, MD, Associate Deputy Editor.
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